The saying used to be, “You can get any paper published if you have enough stamps.” Now with electronic submission, you don’t even need the stamps. A retrospective study comparing single-incision laparoscopic cholecystectomy (SILC) to standard 4-port laparoscopic cholecystectomy (LC) concluded that “SILC showed no disadvantage concerning risk profiles, operative times or hospital stay.” [Emphasis added] According to the abstract, 81.7% of the 115 SILC patients had elective surgery vs. 55.5% of the 344 in the LC group. The SILC cohort experienced significantly shorter operative times (70 ± 31 vs. LC: 80 ± 27 minutes) and hospital lengths of stay (3.02 ± 1.4 vs. LC: 4.6 ± 2.8 days), p < 0.001 for both. LC was converted to open surgery in 21 cases vs. none of the SILCs, p= 0.003. Rates of bile leak and incisional hernia did not differ. Do you see any problems with this study? I do. The groups were not really comparable because the LC group underwent more emergency operations. That difference is significant with a p value of 0.007—conveniently omitted from the abstract. The preponderance of elective cases likely accounts for the SILC group’s shorter operative duration, lower rate of conversion to open, and shorter length of stay. The SILC patients were also a mean of 10 years younger. The average operative time for the LC patients, 80 minutes, is much longer than the 40 to 45 minutes reported in most other recent series such as this one. In statistical circles, measuring one’s pet theory against a false comparator is known as setting up a “straw man.” I’ve written about this before. Complication rates...

Traditionally, the value of medical care has been determined by the effectiveness and safety of a given intervention, regardless of that intervention’s cost. The current goal is to provide the highest-value solutions that are effective, safe, and have the lowest possible cost, according to Craig A. Umscheid, MD, MSCE. “Low-value diagnostic and therapeutic interventions waste patient and prescriber time and money and can even be harmful,” he says. “Low-value care takes away time that providers could be delivering high-value care.” Contributing Factors Defensive medicine practices can be a significant contributor to low-value medical care (Table 1). For example, providers may order diagnostic tests because they are fearful of malpractice suits if there is even the slightest chance that patients could have a disease or condition, says Dr. Umscheid. He discussed his experiences with low-value medical care as a patient in JAMA Internal Medicine. “The healthcare system often supports low-value versus high-value care,” he says. “Physicians who see many patients per day in order to make enough revenue to support their staff, clinic, and livelihood may opt for approaches that are quicker and easier when caring for patients. This strategy may be of low value when compared with approaches that could be taken if physicians had the time and ability to be more invested in their patients’ well-being.” Often, physicians do not know or have access to information about the costs of the diagnostics and therapeutics they prescribe. Others may be unaware of the percentage of costs that patients will assume if they undergo these procedures. “Value can’t be assessed if the costs are unknown,” Dr. Umscheid says. “Further complicating...

[device] Refer your high-risk cardiovascular patients for study participation today! An innovative approach to delivering treatment that does not require needles or pills. ITCA 650 (exenatide in DUROS® device) is an investigational drug product that is being developed for the treatment of Type 2 Diabetes. ITCA 650 is a match stick sized titanium cylinder placed just under the skin in the abdomen where it slowly delivers a continuous and consistent subcutaneous infusion of exenatide for up to six months. Participants must: – be at least 40 years of age – be diagnosed with Type 2 Diabetes for at least 3 months – have a history of coronary, cerebrovascular, or peripheral artery disease Participants will receive: – the investigational product (active treatment or placebo) – all study-related care at no cost For additional details, contact Intarcia today! Via phone at: 1-855-936-2555 Or e-mail: FREEDOMCVOStudy@intarcia.com [/device] [notdevice] Refer your high-risk cardiovascular patients for study participation today! An innovative approach to delivering treatment that does not require needles or pills. ITCA 650 (exenatide in DUROS® device) is an investigational drug product that is being developed for the treatment of Type 2 Diabetes. ITCA 650 is a match stick sized titanium cylinder placed just under the skin in the abdomen where it slowly delivers a continuous and consistent subcutaneous infusion of exenatide for up to six months. Participants must: – be at least 40 years of age – be diagnosed with Type 2 Diabetes for at least 3 months – have a history of coronary, cerebrovascular, or peripheral artery disease Participants will receive: – the investigational product (active treatment or placebo)...

It was a routine Friday night trauma shift, and the team was gathering for what sounded like a TINO—Trauma In Name Only; a rollover MVA with a single driver who self extricated and was walking around at the scene slightly confused but with no obvious signs of injury. I was sitting at the x-ray computer station when the tech came up and said, “Excuse me Doc. I need to log on.” I stood and he caught sight of my face. “Oh, hi Dr. Davis,” he said smiling. “I hoped you’d be on for my first shift. I just started here 2 weeks ago, and this is my first time on nights.” I smiled back, puzzled. He seemed to know me, but I couldn’t place him. He wasn’t one of the regular techs, and I didn’t remember seeing him at the other hospital where I work. His name tag read ‘Larry’, but that didn’t ring any bells. He nodded and said, “I didn’t think you’d recognize me. Ten years ago, when I was sixteen you operated on me and took out half my liver.” It came back to me then. He was a good foot taller and at least 30 pounds heavier, but now that he’d reminded me I knew him. “It’s called Damage Control Surgery. The concept is based on the Navy doctrine of Damage Control on combat ships.” That night, 10 years earlier, he’d been brought in after being hit by a car while skateboarding. He was in shock and going downhill fast. We loaded him with volume, packed red blood cells, saline and later, plasma. This...

The Particulars: Myocardial perfusion imaging (MPI) using cardiac positron emission tomography (PET) is increasingly being used to evaluate patients with suspected or known coronary artery disease (CAD). Whether cardiac PET is an effective gatekeeper to the cardiac catheterization laboratory has not been well defined. Data Breakdown: Researchers who started a perfusion cardiac PET service conducted a study to determine the impact of this service on the rate of normal coronary angiography. Prior to starting the service, the rate of obstructive CAD on angiography was 70.6%, compared with a rate of 73.0% observed among all comers after the service was initiated. The rate of obstructive disease was 81.5% among patients who underwent angiography after cardiac PET, compared with a rate of 72.0% among those who underwent coronary angiography without a preceding cardiac PET. Take Home Pearl: The yield of coronary angiography appears to be significantly higher in patients who undergo cardiac PET prior to coronary...

The Particulars: For patients with a normal baseline ECG who are referred for diagnostic stress testing, current guidelines recommend exercise ECG. Little is known about the added value and prognostic impact of myocardial perfusion single-photon emission (MPS) CT for detecting ischemia. Data Breakdown: Data were analyzed on patients with a normal baseline ECG who underwent an exercise MPS in a study. MPS ischemia was found in 78% of patients with a positive ECG but only 7% off those with a negative ECG. Patients with MPS ischemia had significantly worse long-term survival but similar short-term survival, when compared with those with ECG ischemia. MPS ischemia was a significant predictor of mortality, whereas ECG ischemia was not. Take Home Pearl: The addition of MPS in patients with normal baseline ECGs who are referred for stress testing appears to add to the specificity of ischemia...

The Particulars: Data are lacking on the impact of appropriate use criteria for single-photon emission CT myocardial perfusion imaging (MPI) on the radiation-related lifetime attributable risk (LAR) of cancer and its gender-specific effects. Data Breakdown: For a study, investigators determined adherence to appropriate use criteria among patients who underwent MPI. Patients with inappropriate MPI had a significantly higher LAR of cancer and profoundly lower benefit-to-risk ratios than those with appropriate MPI. Among the inappropriate use group, women had a greater LAR of cancer and profoundly lower benefit-to-risk ratios than men, whereas no differences were observed between genders in the appropriate use group. Take Home Pearl: Inappropriate use of MPI appears to be associated with a higher LAR of cancer and lower benefit-to-risk ratios—especially among women when compared with men—than appropriate MPI...

In 2006, the American Society of Clinical Oncology (ASCO) issued practice guidelines on the follow-up and management of patients with breast cancer who have completed primary therapy with curative intent. Since that time, ASCO completed a 6-year, systematic review and analysis of 14 publications in an effort to update these guidelines. ASCO reissued the recommendations from 2006 in the Journal of Clinical Oncology and came to the conclusion that no revisions to the existing recommendation were warranted. “An important reason behind re-issuing the guidelines is that physicians and patients aren’t always following the recommendations,” explains Thomas J. Smith, MD, a member of the ASCO writing committee for the guidelines. “It has been estimated that more than $1 billion is spent each year on unnecessary breast cancer follow-up care. By re-issuing the guidelines, it’s hoped that clinicians will make greater efforts to adhere to these recommendations.” Assessing Surveillance Research indicates that routine surveillance with PET, CAT, and bone scans—in addition to routine blood tests—is unwarranted in asymptomatic patients with breast cancer. “Physicians tend to deny that they’re ordering these tests, but studies suggest that, in actuality, many clinicians are ordering these diagnostics,” says Dr. Smith. “However, there are no data to date that suggest these tests are beneficial in the management of asymptomatic patients.” Meanwhile, Dr. Smith says other data suggest that patients and physicians do not always obtain tests that are recommended in the guidelines. “Research clearly indicates that patients should undergo a mammogram on the opposite side after definitive surgery for one breast cancer,” he says. “However, study after study has shown that many patients don’t have a...

A surgeon emailed me the following:. OK, I know this is radical but consider my argument… Medical licensing protects no one and costs physicians hundreds to thousands of dollars each year. If a physician is negligent, can the injured party sue the state that licensed him? I’m guessing not. When I moved to my current location, I had to send lots of documentation to the state medical board so they could verify that I was a true and competent surgeon. I provided my employer with the same info so they could also verify my credentials. Now my employer can and will get sued if I commit a negligent act and absolutely should verify my credentials prior to handing me a scalpel. But the state? Its license is useless. Most people choose a surgeon based on recommendations and word-of-mouth reputation, and these are by far better indicators of quality than any credentialing board. Nobody asks to see my license, and, even if they did, it would not protect them any more than their trust in the health system in which I work. If I was in private practice and had my license displayed on my wall, it may give some reassurance to my patients, but it does not say anything about the quality of my work. Most doctors who really screw up due to negligence are licensed by the state. I contend again, that word of mouth and reputation are the best indicators of a surgeon’s ability, anything beyond that is useless. Caveat emptor, “let the buyer beware” remains the mantra of the informed consumer. Thanks for letting me vent....

Few cases of HIV transmission between women who have sex with women (WSW) have been reported in the United States, but these cases still can and do occur. Studies have shown that HIV can be transmitted by female-to-female sexual contact with unprotected exposure to vaginal or other bodily fluids and to blood from menstruation. Historically, confirming HIV transmission during female-to-female sexual contact has been difficult because other risk factors are almost always present or cannot be ruled out. “It can be difficult to determine if HIV was transmitted by female-to-female sex or other more common modes of transmission, such as injection drug use and heterosexual sex,” says Amy Lansky, PhD, MPH. A Case Report According to a report published in the Morbidity & Mortality Weekly Report, the Houston Depart­ment of Health contacted the CDC in August 2012 regarding a rare transmission of HIV that likely resulted from sexual contact between HIV-discordant partners. The women involved reported having unprotected sex during a 6-month monog­amous relationship. The woman with newly acquired HIV did not report any other recognized risk factors for HIV infection. The other partner was previously diagnosed with HIV and had stopped receiving antiretroviral treatment in 2010. In this case, laboratory tests confirmed that the woman with newly diagnosed HIV had a virus that was virtually identical to that of her partner. “This case was unique because the CDC was able to use both phylogenetic and epidemiologic data in the investigation,” Dr. Lansky says. The viruses infecting the two women had a 98% or higher sequence identity in three genes. The couple had not received any preventive counseling before...

Ultrasound contrast agent safety in critically ill patients undergoing echocardiography has been questioned by the FDA. This controversy was the result of rare reports showing that deaths or life-threatening adverse reactions occurred in close proximity to the administration of ultrasound contrast agents. “Since these reports surfaced around 2007, many studies have been conducted to better define the safety profile of these agents,” says Michael L. Main, MD. An Observational Analysis In a large observational study published in JACC: Cardiovascular Imaging, Dr. Main and colleagues compared 48-hour all-cause mortalities and hospital stay mortalities among critically ill patients who underwent echocardiography either with or without an ultrasound contrast agent. Data were collected on more than a million participants through discharge information from a database that included information on primary and secondary diagnoses, procedure billing codes, and demographic and baseline patient information in addition to hospital characteristics. At discharge, more than 990,000 patients underwent echocardiography without a contrast agent, whereas 16,222 received a contrast agent for their exam. According to the results, ultrasound contrast agent use was associated with a 28% lower mortality rate at 48 hours among critically ill patients undergoing echocardiography when compared with no ultrasound contrast agent use. Recipients of ultrasound contrast agents also had significantly lower mortality rates over their entire hospital stay when compared with those who did not receive one (14.85% vs 15.66%). “Importantly, our findings were consistent across a wide variety of major comorbidities and important demographic subgroups, such as age and gender,” says Dr. Main. Overall, there were no groups with significantly greater odds for mortality after receiving a contrast agent. Impactful Findings Data...

Treatment-resistant hypertension (HTN) has been defined in various ways in clinical research. Some definitions go so far as to say which medications should be used before classifying patients as having resistant HTN. Regardless of the definition, the overriding theme of treatment-resistant HTN is that it occurs when several anti-hypertensive drugs are needed to control blood pressure (BP). Studies suggest that treatment-resistant HTN is present in 20% to 30% of patients with HTN. Its prevalence has more than doubled over the past 25 years, and research has linked it to an increased risk of cardiovascular events when compared with patients without treatment-resistant HTN. “The topic of treatment-resistant HTN has gained attention in recent years,” says Rhonda M. Cooper-DeHoff, PharmD, MS, FAHA, FACC. “The condition increases long-term risk for poor outcomes, regardless of whether or not HTN is controlled or uncontrolled. Unfortunately, we’re lacking important data on the long-term effects of treatment-resistant HTN.” Coronary artery disease (CAD) is among the leading causes of mortality, and treatment-resistant HTN is more common in patients with CAD than without CAD. Little is known, however, about the impact that treatment-resistant HTN has on cardiovascular outcomes in patients with CAD. Such data may inform clinicians on strategies to aggressively manage risk factors. Identifying Predictors & Impact In the Journal of Hypertension, Dr. Cooper-DeHoff and colleagues published a study that described the prevalence, predictors, and impact on adverse cardiovascular outcomes of resistant HTN among patients with CAD and HTN. More than 17,000 study participants were divided into three groups according to achieved BP: 1) controlled (BP<140/90 mm Hg on three or fewer drugs); 2) uncontrolled (BP≥140/90 mm Hg on...

Crowding in the ED has been well-established as a problem that poses a threat to public health. Studies show that ED and hospital crowding leads to ambulance diversions, medical errors, delayed care, and increased mortality rates. “Many strategies have been tried to alleviate ED and hospital crowding, some of which involve the entire institution,” explains Peter Viccellio, MD. Using a Full-Capacity Protocol One strategy that aims to reduce ED crowding is the use of a full-capacity protocol (FCP), in which admitted ED patients are redistributed to inpatient unit hallways while they wait for regular hospital beds to open up. Some studies have shown that an FCP can decrease ED wait times, ambulance diversions, and overall hospital length of stay. A potential concern with this approach, however, is that it could reduce patient satisfaction. Recently, Dr. Viccellio and colleagues had a study published in the Journal of Emergency Medicine that examined patient preference and satisfaction with boarding in the ED versus inpatient hallways during times when there were no inpatient beds available for admitted patients. All patients were initially boarded in the ED in a hallway before their transfer to an inpatient hallway bed. “No more than two patients in our study were placed on any inpatient unit and all patients received direct care from inpatient physicians and nurse specialists,” adds Dr. Viccellio. “We didn’t compare a room versus a hallway. Rather, we looked at making decisions about where patients can receive the best care and greatest attention in difficult circumstances when a normal room is not available.” Overwhelming Results According to the results, the overall preferred location after admission...

Both men and women share many of the same high-risk predictors for stroke, such as smoking, family history, and physical inactivity. However, some risk factors are either exclusive to women or affect women disproportionately. The American Heart Association (AHA) and American Stroke Association (ASA) recently convened a panel of experts in neurology, obstetrics, cardiology, epidemiology, and internal medicine to review and assess the literature on stroke risk in adults. This resulted in the publishing of the first gender-specific AHA/ASA guidelines for stroke prevention in women. “The development of these guidelines is important because women differ from men in many ways with regard to stroke,” explains Cheryl B. Bushnell, MD, who chaired the AHA/ASA writing group that developed the document. Several characteristics can influence stroke risk and impact outcomes, including genetic differences in immunity, coagulation, hormonal factors, reproductive factors (eg, pregnancy and childbirth), and social factors. “Many of the unique risk factors for women present at younger ages due to things like oral contraceptive use and pregnancy complications,” Dr. Bushnell explains. “Recognition of stroke risk and identification of prevention strategies could start early in at-risk women.” Highlighting Key Recommendations Based on available evidence, the AHA/ASA guidelines categorized risk factors by those that were sex-specific, more prevalent in women, or similar between women and men (Table 1). Dr. Bushnell says it is critical to recognize that women with a history of hypertension or preeclampsia during pregnancy are at risk for stroke and hypertension later in life. “Before this guideline emerged, few providers and women knew about this risk,” she says. “The evidence for this relationship is strong, and multiple meta-analyses have...

Studies have shown that red blood cell (RBC) transfusions are commonly performed, with approximately 14 million units transfused in 2011 in the United States. RBC transfusions can modulate the immune system, which in turn may impact infection risk. One approach in blood management is to use a restrictive threshold transfusion strategy in which the hemoglobin thresholds at which RBC transfusions are indicated are lowered. “The restrictive strategy is recommended by guidelines, but only about 27% of hospitals report using them after surgery,” says Jeffrey M. Rohde, MD. In addition, only 31% of hospitals report having a blood management program in place to optimize the care of patients who might need a transfusion. A Systematic Review & Meta-Analysis Dr. Rohde and colleagues conducted a systematic review and meta-analysis of 21 randomized trials that compared restrictive and liberal RBC transfusion strategies. Published in JAMA, the article evaluated whether RBC transfusion thresholds were associated with risk of infection and whether these risks were independent of leukocyte reduction. The study included more than 8,700 patients who met eligibility criteria. All healthcare-associated infections reported after receiving donor blood in randomized trials were evaluated, including serious infections like pneumonia and bloodstream and wound infections. According to the results, a restrictive RBC transfusion strategy reduced the risk of healthcare-associated infections when compared with a liberal transfusion strategy. “The more RBCs that patients received, the greater their risk was for infection,” says Dr. Rohde. “The fewer the RBC transfusions, the less likely hospitalized patients were to develop infections.” He adds that these findings were most likely due to transfusion-associated immunomodulation. Overall, for every 38 hospitalized patients considered...

According to recent estimates, approximately 62,980 people in the United States will be diagnosed with thyroid cancer in 2014, a nearly 5% increase from 2013. The incidence is rapidly increasing among all age groups, and thyroid cancer is especially common in women, who represent three of every four people diagnosed with the disease. September is recognized internationally as Thyroid Cancer Awareness Month, and ThyCa: Thyroid Cancer Survivors’ Association sponsors this observance to raise awareness. ThyCa (www.thyca.org) provides free handbooks, education, support services, events, and awareness materials to patients, professionals, and the public by mail and by download. Not a “Good Cancer” “A common misconception about thyroid cancer is that it’s often called a ‘good cancer’ because the prognosis for most patients is excellent,” says Gary Bloom. “This undermines the seriousness of the disease. When clinicians diagnose thyroid cancer, it’s an opportunity to deliver messages in a way that patients understand the gravity of their situation. While most patients do well, there is still a lifelong risk for recurrence. These patients all need to be monitored consistently for their thyroid health.” Early detection of thyroid cancer is critical because the disease is usually treatable when caught early. However, some thyroid cancers are more aggressive and difficult to treat, further illustrating the importance of early detection. Physicians can perform a simple neck check that can be completed in seconds, and this brief exam can help improve outcomes. “Physicians can encourage patients to be regularly checked for thyroid nodules,” Bloom says. “When a diagnosis is made, physicians can advise bringing a friend, family member, or caregiver to help patients understand the diagnosis...

According to national estimates, stroke is the third leading cause of death among women in the United States, and the aftermath of these events is significant among survivors. Studies have found that about one-third of women who survive a stroke will need help caring for themselves, whereas 16% will require institutional care, and 7% will have an impaired ability to work. Each year, about 55,000 more women than men will have a stroke. There has also been a rise in stroke prevalence among middle-aged women that has not been seen in their male counterparts, highlighting the need for a better understanding of stroke among women of all ages. Research has shown that women from racial and ethnic minority backgrounds experience a disproportionate stroke burden. For example, African-American women have an incidental stroke risk that is almost twice as high as that of Caucasian women. Some studies indicate that the prevalence of stroke risk factors may be higher among Hispanic women. “Considering these risks, it’s important to assess the ability of women to recognize stroke warning signs at their onset,” says Heidi Mochari-Greenberger, PhD, MPH. “Early recognition may lead to more rapid access to emergency care, which in turn may result in decreased stroke-related morbidity and mortality.” Surveying the Scene To improve outcomes and reduce disparities, it is important to address gaps in women’s knowledge as it relates to stroke warning signs. In 2012, the American Heart Association (AHA) commissioned a national survey to determine women’s cardiovascular disease awareness. This survey also included an assessment of knowledge relating to stroke warning signs. For a study published in Stroke, Dr....